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Optimizing Care for PWIDs

Optimizing Care for PWIDs. Frederick L. Altice, M.D. Director of Clinical and Community Research Professor of Medicine Yale University. The Doctor-Patient Relationship. Hippocratic Oath. First do no harm.

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Optimizing Care for PWIDs

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  1. Optimizing Care for PWIDs Frederick L. Altice, M.D. Director of Clinical and Community Research Professor of Medicine Yale University

  2. The Doctor-Patient Relationship

  3. Hippocratic Oath • First do no harm. • I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick. • I will prevent disease whenever I can, for prevention is preferable to cure.

  4. The Future HIV Healthcare Providers: Professional Students in Malaysia P=0.001 P=0.001 P=0.001 P=NS

  5. Percent Who Would Defer Antiretroviral Therapy

  6. Definition: Syndemic • A set of linked health problems involving two or more conditions, interacting synergistically, and contributing to excess burden of disease in a population. • Syndemics occur when health-related problems cluster by person, place, or time.

  7. Triple Layers of Stigma HIV Arrest Incarceration Substance Use Disorder

  8. Substance Use Disorder Infectious Diseases (HIV, HCV, TB) Mental Illness (Mood or Thought Disorders)

  9. High Low ADDICTION IS A DISEASE OF THE BRAIN as other diseases it affects the tissue function Decreased Brain Metabolism in Addiction Patient Healthy Control Cocaine Abuse Decreased Heart Metabolism in Heart Disease Patient Healthy Heart Diseased Heart Sources: From the laboratories of Drs. N. Volkow and H. Schelbert

  10. Biology/Genes Environment Beth Carter Richard Hill Alice Benson Rebecca Wilson Mary Walters Susan Edwards Allison Fields Edward Bryson JonathanCook Thomas Jones EdwardSmith William Price JaneJones Steven Adams Amy Mason John Walker DRUG Walter Jones John Smith Alice Price James Hill Susan Adams JaneWalker JamesCook Beth Bryson AnneCook Mary Hill ThomasSmith John Jones Ann Jones James Smith Brain Mechanisms John Smith Addiction ADDICTION INVOLVES MULTIPLE FACTORS

  11. Reward (Pleasure) Pathway Alcohol Stimulants Heroin Stimulants Heroin Nicotine Ventral Tegmental Area

  12. HIV OST Mental Illness Medical Care The Problem!

  13. Secondary HIV Prevention and Adherence Counseling Pharmacologist Addiction Treatment Specialist Integrating Care for PLWHA

  14. Guidelines for Integrating Collaborative Services • Common comorbidities in people who use drugs • TB, HIV, HCV, STIs • Mental illness • Studies where services are NOT integrated have poorer treatment outcomes – patients don’t travel to new sites for treatment (convenience, mistrust, etc)

  15. Integration is Internationally Recommended

  16. Steps in Organizational Change Toward Healthcare Integration OAT OAT OAT HIV/OAT Coordination HIV Communication HIV HIV SeparateSites CompleteIntegration Co-LocatedServices PartialIntegration

  17. Specific Recommendations for PLH and SUDs • Prescribing opioid agonist therapy with either methadone or buprenorphine for individuals with opioid use disorders • Integration of HIV and addiction services • Directly administered antiretroviral therapy (DAART), including into methadone treatment

  18. Portugal Experience (Decentralization) Prisons Addiction Centers TB Centers Hospitals: Integrated Services Primary Care Centers Pharmacies Testing Center Outreach Teams ART OAT TB treatment HCV treatment HIV testing NSP TB screening

  19. Addiction Integration into Primary Care • Correlates of retention on buprenorphine: • Having a primary care rather than an addiction specialist prescribing treatment • Not using cocaine • Being prescribed anti-depressant medications • Receipt of addiction counseling

  20. Addiction Integration into Primary Care • Correlates of higher quality health indicators: • Having a primary care rather than an addiction traetment doctor prescribing treatment • Being retained on buprenorphine ≥3 months • Being HIV-infected • Male gender

  21. Quality Health Indicators

  22. Altice, JAIDS, 2011

  23. Required multiple prescribers within a “practice” • Needed a “glue” person to anchor the program (counselor, nurse, etc) • Challenges of “culture” between HIV and addiction and new practices (urine screens) • Polysubstance use and mental illness comorbidities created additional challenges

  24. Integration in Ukraine: Improvements in Health

  25. Overview • Cross-sectional study of 296 HIV+ opioid dependent patients in Kiev and Dnipropetrovsk regions in Fall 2010 • Randomly recruited from three settings • Integrated & Co-Located Clinics (ICL) • Non-Co-Located Narcology Clinics (NCL) • Harm Reduction & Outreach Sites (HRO) • Primary Outcomes • Performance on Quality Health Indicators (QHI) • Health-related Quality of Life (HRQoL)

  26. Quality Health Indicators • An index that is created to measure health outcomes across a number of diseases • HIV Index (N=3) • CD4 monitoring in previous 6 months; receipt of ART; receipt of ART if CD4<200 • OST Index (N=3) • Methadone dose ≥80mg; any IDU in previous 30 days; daily IDU in previous 30 days • TB Index (N=2) • TB screening in past 12 months; isoniazid preventive therapy

  27. HIV Quality Indicators

  28. OAT Quality Indicators

  29. TB Quality Indicators

  30. Mean Quality Health Indicator Score P<.001 P<.001

  31. Health-Related Quality of Life P<0.001 P<0.001

  32. Health Services IntegrationOAT and TB TreatmentOAT and HCV Treatment

  33. OAT and TB Treatment Hospitalized Patients in Ukraine P=0.031 P=0.009 P,0.001 Morozova et al, IJDP, 2013

  34. South Central Rehabilitation Center

  35. SCRC Services Provided • Treatment for alcohol and substance use disorders, including 7 day inpatient detoxification • Methadone and buprenorphine maintenance • Routine screening of ALL patients for HIV, TB, HBV, HCV and mental illness • Onsite treatment for HIV, HCV and uncomplicated mental illness • DOT for HIV, HCV and TB prophylaxis treatment

  36. OAT and HCV TreatmentOnsite vs Referral for HCV Treatment

  37. The Solution! HIV OST Medical Care Mental Illness

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